What is the treatment for an itchy rectum (pruritus ani)?

Treatment of Itchy Rectum (Pruritus Ani)

The first-line treatment for pruritus ani is proper perianal hygiene combined with 1% hydrocortisone ointment applied to the affected area no more than 3-4 times daily for short-term relief of symptoms. 1, 2

Causes and Evaluation

Pruritus ani can be caused by various factors that should be identified and addressed:

• Common causes:

  • Inadequate hygiene
  • Minor fecal incontinence
  • Perianal dermatitis
  • Hemorrhoids
  • Skin conditions (eczema, psoriasis)
  • Infections (fungal, bacterial, parasitic)
  • Dietary irritants

• Less common causes:

  • Systemic diseases (diabetes, liver or kidney disease)
  • Medication side effects
  • Psychological factors

Treatment Algorithm

Step 1: Improve Perianal Hygiene

• Clean the affected area with mild soap and warm water
• Gently dry by patting (not rubbing) with soft toilet tissue or cloth
• Avoid using scented toilet paper, soaps, or wipes
• Use unscented, soft toilet paper
• Consider using a bidet or shower after bowel movements

Step 2: Topical Treatments

• First-line: 1% hydrocortisone ointment applied up to 3-4 times daily for 1-2 weeks 1, 2

  • Research shows 68% reduction in itching with hydrocortisone compared to placebo
  • Also improves quality of life and clinical appearance of perianal skin

• For persistent cases:

  • Barrier emollients to protect skin
  • Low-potency topical corticosteroids for short-term use
  • Capsaicin cream or tacrolimus ointment for recalcitrant cases 3

Step 3: Address Underlying Causes

For Hemorrhoids:

• Increase dietary fiber and fluid intake
• Consider over-the-counter fiber supplements
• Refer for surgical evaluation if symptoms persist or hemorrhoids are large 4

For Infections:

• Pinworm infection: Albendazole 400 mg or mebendazole 100 mg as a single dose 5
• Fungal infections: Topical azole preparations 5

For Skin Conditions:

• Treat according to specific dermatological diagnosis
• Consider dermatology referral for persistent cases

Step 4: Lifestyle Modifications

• Dietary changes:

  • Avoid potential dietary triggers (coffee, tea, cola, chocolate, citrus, tomatoes, spicy foods)
  • Increase fiber intake to improve stool consistency

• Clothing recommendations:

  • Wear loose-fitting cotton underwear
  • Change underwear daily
  • Avoid tight clothing

Special Considerations

• Chronic cases: If symptoms persist beyond 4-6 weeks despite treatment, refer to a specialist (proctologist, gastroenterologist, or dermatologist) 6

• Avoid common pitfalls:

  • Prolonged use of potent corticosteroids (can cause skin atrophy)
  • Excessive cleaning (can worsen irritation)
  • Scratching (perpetuates the itch-scratch cycle)
  • Self-medication without identifying underlying cause

• For idiopathic cases:

  • Consider methylene blue injection (tattooing) for refractory cases 6
  • Biofeedback may be helpful if functional rectal pain is present 3

When to Refer

• Symptoms persisting beyond 4-6 weeks despite treatment
• Suspicion of underlying malignancy
• Presence of blood in stool
• Complex anorectal conditions (fistulas, abscesses)
• Recurrent symptoms despite appropriate treatment

Early identification and treatment of pruritus ani leads to better outcomes, with success rates of over 90% when treated promptly, compared to 76% when treatment is delayed 6.